Medical Records Technician (Coder) Auditor - Veterans Affairs, Veterans Health Administration (Arkansas)

Summary This position is in the Health Information Management (HIM) section at the Veterans Health Care System of the Ozarks located in Fayetteville, Arkansas. Medical Records Technicians (MRTs), Coder-Auditor are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. Responsibilities If you are not a current, permanent VA employee, you should apply using announcement: CBST-11097598-21-AH Duties may include but are not limited to: Analyzes and abstracts patients' health records and assigns alpha-numeric codes for each diagnosis and procedure. Possesses expertise in International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS). Provides education related to coding and documentation. Researches complex coding issues and participates in process improvements related to coding. Serves as expert of current coding conventions and guidelines related to professional and facility coding. Performs audits of encounters to identify areas of non-compliance in coding. Facilitates improved overall quality, completeness, and accuracy of coded data; provides recommendations on appropriate coding and is responsible for maintaining current knowledge of the various regulatory guidelines and requirements. Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided. Provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Consults directly with the clinical staff for clarification of conflicting or ambiguous clinical data. Utilizes computer applications with varied functions to produce a wide range of reports, to abstract records, and review assigned codes. Performs prospective and retrospective coding audits and utilizes results to identify documentation and coding inadequacies and re-educate clinical and coding staff based on audit results. Independently plans, organizes, and performs auditing with emphasis on data validation, analysis, and generation of reports. Assists in the development of guidelines for data quality, consistency, and monitoring for compliance in order to improve the quality for clinical, financial, and administrative data to ensure that all coded data is fully documented and supported. Maintains statistical database(s) to track results and validate the program; identifies patterns and variations in coding practices with regular reports to the medical staff and management. Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Work Schedule: Monday-Friday, 8:00AM-4:30PM. Financial Disclosure Report: Not required. Requirements Conditions of Employment Qualifications Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. Experience and Education:(1)Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR, (2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management (e.g., courses in medical terminology, anatomy and physiology, medical coding, and introduction to health records); OR, (3) Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been accredited by a national U.S. Department of Education accreditor, or comparable international accrediting authority at the time the program was completed; OR, (4) Experience/Education Combination. Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. The following educational/training substitutions are appropriate for combining education and creditable experience:(a)Six months of creditable experience that indicates knowledge of medical terminology, general understanding of medical coding and the health record, and one year above high school, with a minimum of 6 semester hours of health information technology courses.(b)Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service, under close medical and professional supervision, may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and health record techniques and procedures. Also, requires six additional months of creditable experience that is paid or non-paid employment equivalent to a MRT (Coder). Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either (1), (2), or (3) below: (1)Apprentice/Associate Level Certification through AHIMA or AAPC. (2)Mastery Level Certification through AHIMA or AAPC. (3)Clinical Documentation Improvement Certification through AHIMA or ACDIS. English Language Proficiency: MRTs (Coder) must be proficient in spoken and written English as required by 38 U.S.C. § 7403(f). May qualify based on being covered by the Grandfathering Provision as described in the VA Qualification Standard for this occupation (only applicable to current VHA employees who are in this occupation and meet the criteria). Preferred Experience: At least one year of VA coding experience. Grade Determinations: In addition to the basic requirements for employment described above, the following criteria must be met when determining the grade of candidates: Medical Records Technician (Coder) Auditor, GS-9: Experience: One year of creditable experience equivalent to the journey grade level (GS-8) of a MRT (Coder). Certification: Employees at this level must have a mastery level certification. Mastery Level Certification: This is considered a higher-level health information management or coding certification and is limited to certification obtained through AHIMA or AAPC. To be acceptable for qualifications, the specific certification must represent a comprehensive competency in the occupation. Stand-alone specialty certifications do not meet the definition of mastery level certification and are not acceptable for qualifications. Certification titles may change and certifications that meet the definition of mastery level certification may be added/removed by the above certifying bodies. However, current mastery level certifications include: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P),Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Outpatient Coder(COC), Certified Inpatient Coder (CIC). NOTE: COPY OF CURRENT MASTERY LEVEL CERTIFICATION IS REQUIRED AT TIME OF APPLICATION. Demonstrated Knowledge, Skills, and Abilities. In addition to the experience above, the candidate must demonstrate all of the following KSAs: i. Advanced knowledge of current coding classification systems such as ICD, CPT, and HCPCS for the subspecialty being assigned (outpatient, inpatient, outpatient and inpatient combined). ii. Ability to research and solve complex questions related to coding conventions and guidelines in an accurate and timely manner. iii. Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions and guidelines, and documentation requirements. iv. Ability to format and present audit results, identify trends, and provide guidance to improve accuracy. v. Skill in interpersonal relations and conflict resolution to deal with individuals at all organizational levels. NOTE: KSAs MUST BE CLEARLY REFLECTED IN RESUME UNDER DESCRIPTION OF DUTIES IN ORDER TO BE FOUND QUALIFIED FOR THIS POSITION/GRADE LEVEL. References: VA Handbook 5005/122, PART II, APPENDIX G57. This position is above the Full Performance/Journey Level, GS-9. Physical Requirements: Work is primarily sedentary. Employee generally sits to do the work. There may be some walking, standing, or carrying of light items such as patient charts/ records, manuals or files. Employee also extracts information from computer systems which requires ability to utilize keyboards or other similar devices Education IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education. Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html. Additional Information This job opportunity announcement may be used to fill additional vacancies. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members. If you are unable to apply online view the following link for information regarding an Alternate Application.

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